Article 20

MMORPG in Women: Diagnosis and Treatment

Adrianne L. Johnson

Johnson, Adrianne L., is an Assistant Professor of Clinical Mental Health Counseling at Wright State University. Her experience includes adult outpatient, college, crisis, and rehabilitation counseling. She has presented internationally on a broad range of counseling and counselor education topics, and her research interests include bias and diversity in counseling and counselor education. Abstract This article explores the understudied topic of MMORPG addiction in women and associated diagnostic characteristics as articulated by the American Psychiatric Association (2013). It is currently estimated that almost half of players are female, and women generally tend to select online roleplaying games (MMORPGs) as their preferred video game due to gender-specific social characteristics. Understanding the motivations for female MMORPG players and specifically identifying these characteristics may help counselors discern leisure play from addiction and will aid in the appropriate formation of treatment strategies and future research.

Introduction

Recent scientific reports have begun to focus on the preoccupation that individuals develop with certain aspects of the Internet, particularly online games (American Psychiatric Association [APA], 2013b). The concept of a gaming addiction focuses on the symptoms which arise when this preoccupation transcends into compulsive playing, resulting in the exclusion of other interests and clinically significant impairment or distress from a player’s persistent and recurrent online activity. Specifically, players may endanger their academic or job functioning because of the amount of time they spend playing, and experience symptoms of withdrawal when consistent exposure to the game is ceased. Much of the current literature related to gaming addiction cumulatively emphasizes the addictive qualities of MMORPGs, or Massively Multiplayer Online Roleplaying Games. These games are reality-based computer (video) games and are often referred to as ‘roleplaying’ games. Researchers generally limit their samples to young Asian males, 12-20 years of age (APA, 2013a, p. 797), and findings suggest that the prevalence of diagnosable Internet-related addictive symptoms are 1-15% higher in men than women. The researchers of these studies suggested that when these individuals are engrossed in Internet games, certain pathways in their brains are triggered in the same Ideas and Research You Can Use: VISTAS 2014 direct and intense way that a drug addict’s brain is affected by a particular substance. The gaming prompts a neurological response that influences feelings of pleasure and reward, and the result, in the extreme, is manifested as (APA, 2013b). Bleckmann, Eckert, and Jukschat (2012) referred to this phenomenon as “video game dependency” (p. 137), and it is defined as an "addiction" by the Chinese government (APA, 2013a, p. 797). While a few treatment centers focused on gaming addiction symptoms exist in Asia and in the United States, a prescribed effective treatment regimen is still to be determined.

MMORPGs

MMORPGs offer alternate realities, available 24 hours a day, and the average player ‘logs on’ for at least 20 hours per week. The primary intention of these roleplaying games, or “imaginary-entertainment-environments” (Mackay, 2001, p. 32) is the creation of a shared and co-created imaginal space between the “real world” and “fantasy” where the intersection of person, player, and characters is played out (Dyszelski, 2006, p. 235). The permeability of these boundaries allows popular culture references to slip into and enrich the fantasy space while the adventure, excitement, and vicarious thrills of acting the part of hero can enrich the gaming experience of the players. Hughes (1988) described roleplaying as “a recreational activity is a translation of private fantasy activities such as daydreaming into social and game context that is structured and controlled by an agreed set of rules” (Roleplaying section, para. 1). Players each create a screen character, choosing its gender, name, profession, and often an allegiance within the game. These characters can communicate with one another through typed messages. While the characters in traditional computer games tend to be fighters, MMORPGs allow players to choose from a variety of ‘professions’ (e.g., tailor, chef, blacksmith, or warrior) and then devote hours to building their skills and strengths in their chosen professions. Characters have the option to kill other players, or to cooperate as law-abiding citizens and artisans (Laber, 2001). Non- may think of MMORPGs as imaginative childhood games like “Cops and Robbers” (Dyszelski, 2006, p. 10).

Women and MMORPGs

Krotoski (2004) estimated that 41% of women report having an electronic gaming system in their household, and while they may not be the primary users of this technology, anecdotal evidence suggests that game helplines see a spike in the number of phone calls from adult women during school hours. It is estimated that at least 20 to 30% of video game players are women and that 53% of game titles are purchased by women (Laber, 2001). Griffiths, Davies, and Chappell (2004) found that the majority of female game players are between 20 and 70 years of age, and Williams, Yee, and Caplan (2008) found that while males currently comprise the majority of video game players, women report playing more often than men (29.31 hours per week versus 25.03 hours per week, respectively). Researchers suggest female gamers traditionally adopt software that encourages self-reflection, social interaction, and proficiency. Myers (1990) found that while both men and women feel that a challenge is an important characteristic of game play, women

2 Ideas and Research You Can Use: VISTAS 2014 prefer games that make them laugh (Mehrabian & Wixen, 1986). Taylor (2003) suggested that women are also drawn to this genre of game because they enjoy gaming within social communities which encourage exploration of an environment with others as a team, allow for the opportunity to play out different aspects of self-identity in a safe setting, and support the pleasure associated with success. Women additionally indicate that identifying with a character is important to their enjoyment of a game, and they prefer the presence of a good plot, rich characterizations, choice in how they pursue goals, freedom of self-expression, novelty in challenges, immersion in atmospheric virtual environments, pickup-and-play capabilities, and flexibility (Krotoski, 2004). Women and men both hold leadership roles in these games, heading local governments, military alliances, and other groups. Game developers suggest that what most distinguishes women players is the use of their imaginations to push the limits of the games, and subsequently, pioneering ingenious new kinds of player contacts (Laber, 2001). Krotoski (2004) suggested that as more women have been vocal about their game playing, there has been an increase in strong female protagonists. For example, some characters played by women join together to critique other players’ outfits, or to offer their help to new players who are learning the mechanics of the game.

Diagnosis and Treatment of MMORPG Addiction in Women

Griffiths (2008) suggested that “the difference between healthy excessive enthusiasms and are that healthy excessive enthusiasms add to a person’s life whereas addictions take away from it” (p. 120). Researchers have indicated that an important aspect of the sense of involvement in any leisured female activity is a community of similar-minded women with whom to share experiences and form new ones (Sorensen, Faulkner, & Rommes, 2012). Hughes (1988) even suggested that these games can transform lives, and gives an example of a roleplaying game which helped a woman cope with, and recover from, . However, MMORPGs are a form of Internet usage that is stereotypically associated with pathological Internet use (Morahan- Martin & Schumacher, 2000); therefore, it is important to discern the line between important and beneficial leisure, and the problematic symptoms of addiction. For example, Yee (2006) suggested that individuals with low self-esteem use MMORPGs to compensate by creating an avatar which is powerful and competent in these online environments, which allows the player to overcome which may be impaired in the real world. Thus, women who feel undervalued in the real world can create a sense of value for themselves through collaboration with teammates and the creation of a ‘family-like’ atmosphere. Women may also displace a poor self-image for a physically agile avatar and subsequently gain a stronger sense of empowerment and agency. This undermines their own empowerment and self-acceptance. MMORPGs allow individuals to escape everyday real-world problems by immersing themselves in a fantasy world; a possibility that is particularly attractive to people whose personalities and social skills lead to problems in real-world environments (Attwood, 2006). The playing of such games can allow women to develop supportive and warm relationships that they may lack offline with reduced risk of perceived social entanglement (Charlton & Danforth, 2007). For female MMORPG players who

3 Ideas and Research You Can Use: VISTAS 2014 experience positive and negative feedback, however, the benefit of a situation-specific nonverbal is absent, which serves to enhance existing avoidance behaviors. For women whose psychological characteristics or life circumstances make them vulnerable to behavioral addictions, MMORPGs may be particularly problematic due to the absence of reinforcement and behavioral cues which they would expect to encounter in real life. Counselors may identify several underlying reasons for the addictive symptoms which patients exhibit in association with MMORPGs.

Diagnosis Charlton and Danforth (2007) emphasized the need for distinguishing (pathological) computing-related addictions from (non-pathological) high engagement in computing activities. Making this distinction between addiction and engagement is essential when assigning a diagnosis and formulating a treatment plan which addresses social deficits and behavioral dysfunction. The Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5, American Psychiatric Association [APA], 2013a) has suggested the need for an independent addiction disorder addressing this issue and has proposed Internet Gaming Disorder, defined as: “a pattern of excessive and prolonged Internet gaming that results in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of substance use disorders (p. 797), and notes that the description of criteria related to this condition is adapted from a study in China. The American Psychiatric Association proposes the following criteria for Internet Gaming Disorder: “Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12- month period (p. 795).” 1. Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life). Note: This disorder is distinct from Internet gambling, which is included under gambling disorder. 2. Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typically described as irritability, , or sadness, but there are no physical signs of pharmacological withdrawal.) 3. Tolerance—the need to spend increasing amounts of time engaged in Internet games. 4. Unsuccessful attempts to control the participation in Internet games. 5. Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games. 6. Continued excessive use of Internet games despite knowledge of psychosocial problems. 7. Has deceived family members, counselors, or others regarding the amount of Internet gaming. 8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety). 9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games.

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Further, Bleckmann et al. (2012) found that the rates and patterns of comorbidity with other disorders, primarily depressive disorders, are comparable to that of substance- related addictions, and found that frequent accounts of depression and trauma are highly correlated with diagnosable symptoms of an existing gaming addiction in women.

Treatment Currently there is no evidence to support a specific treatment approach to video game, and MMORPG-specific, addiction. The literature which addresses Internet and gaming addictions suggests broad and inconsistent approaches which require further research, and there is no existing literature which discusses effective therapeutic treatments specifically for women who exhibit addictive symptoms related to MMORPGs. However, Griffiths (2008) suggested that MMORPG addiction may be compared to a nonfinancial form of gambling, and that counselors often use gambling- based questionnaires and motivational interviewing strategies to address associated addictive behavior. Individual therapy. Griffiths (2010) suggested that a cyclic behavioral component is present in video game addiction symptoms which are directly analogous to a diagnosable gambling addiction paradigm, and described six core criteria which counselors should be aware of: salience (when gaming dominates thinking and behavior even when the player is not online), mood modification (the player experiences euphoria or a “buzz” or a feeling of escape when playing), tolerance (increased game play is required to achieve the buzz or escape), withdrawal symptoms (players feel irritable or anxious when not playing), conflict (real-world responsibilities are neglected, and the player feels a loss of control), and relapse (despite attempts to not log on, the player returns to the game; p. 120). Utilizing Griffiths’ (2010) model concepts, current literature generally suggests the application of treatments which show efficacy in the treatment of chemical addictions, such as behavior modification or motivational interviewing techniques. Many chemical addictions promote chemical abstinence in patients as a prescribed treatment plan; however, Yee (2002) proposed that urging an individual to abstain from an MMORPG completely may only intensify the addiction since the psychological needs would have no immediate tangible rewards system in place. There is no research to support nor refute this assertion as a viable therapeutic approach for the treatment of gaming addiction symptoms. Treatment centers. There are few treatment centers which exist for the purpose of exclusively addressing gaming addiction symptoms, and no centers exist which are designed for treating female patients specifically. Two existing models of treatment are briefly discussed in the literature; however, Beijing has adopted a military-style treatment plan which emphasizes confidence-building and addressing psychological dysfunction which leads to excessive gaming, over a three-month timespan (Barnett & Coulson, 2010), and treatment facilities in the Netherlands address the psychological needs of each individual and help them to focus on developing a career, healthy relationships, and spiritual growth, while attending to the more practical sides of recovery by providing financial and nutritional advice. Bleckmann et al. (2012) suggested that treatment facilities screen for dual diagnoses, and include the following in the treatment plan for female patients: consider gender-specific strategies; address subjective gaming motives in

5 Ideas and Research You Can Use: VISTAS 2014 the biographical context; and be aware of possible underlying traumatic experiences and mental health problems (p. 145). Counselor effectiveness. There is high potential for counselors to utilize MMORPG’s as behavioral skill-building tools in practice, and counselors do not need to be ‘gamers’ to help female patients comprehend their participatory roles in these games. Further, as patients build their self-awareness regarding their motivations for gaming activities, the therapeutic relationship takes on an educational component about the qualities of leisure versus the symptoms of addiction. Hughes (1988) suggested that MMORPGs offer three primary benefits to players: providing an escape from social pressure; aiding in increasing one’s sense of personal control; and developing social skills. These games often allow players to experience a strong sense of personal efficacy and achievement through an identification with their exploits, and many players additionally experience a strong cathartic release which may be inappropriate in other ‘real life’ contexts. MMORPGs create unique cultural systems and structure, and this provides players with a set of rules which guide their behavior and illustrate social boundaries. Social structure, norms, values, and constructs define what is, and what is not, appropriate behavior in a particular setting. For female patients, it may be particularly useful for counselors to build on these empowering benefits and to engage the patient in behavioral rehearsal for the benefit of developing self-efficacy and assertiveness, and learning and monitoring emotional regulation skills. Further, many MMORPG players are encouraged by practicing novel social strategies while preserving their anonymity. These are shared cultural systems among players, and players find themselves voluntarily participating in the evolution of these systems. For female patients specifically, there are Web sites which offer women the opportunity to engage in social constructivsm. These Web sites provide a medium for women to express their gaming interests and to communicate about computer gaming culture from their perspective, as well as to meet other women for online gaming (Krotoski, 2004). Counselors may find it useful to utilize such sites to help female patients practice adaptive social skills and appropriate boundary-setting while maintaining their privacy and addressing other salient context-related issues.

Future Considerations

Further research is needed to establish the identifiable criteria for the diagnosis of gaming addiction in women. Although a few Chinese studies exist, there is a lack of Western studies specifically correlating personality and game playing variables in the peer-reviewed literature. It is important to note that most studies regarding Internet and gaming addictions have been focused on Asian countries, and primarily on young males. Currently, the authors of these studies have correlated personality variables with Internet usage and addiction more generally, and some of these studies are now considered when formulating hypotheses regarding the generalization of data on MMORPG playing to women (Wang & He, 2000). It is also important for counselors to be aware of the suggestions that using the term ‘addiction’ in connection with non-chemically-related behaviors is argued to trivialize chemical addictions (Jaffe, 1990). Despite the fact that some clinics in the U.S.

6 Ideas and Research You Can Use: VISTAS 2014 and Europe now offer treatments for Internet and computer gaming addictions, this position proposes that, with respect to the playing of MMORPGs where in general the negative life outcomes for people classifiable as addicted, the symptoms and consequences for people who meet the DSM-5 (APA, 2013a) criteria are often less severe than individuals who are behaviorally addicted to activities such as gambling or chemical dependency (Jaffe, 1990). Regarding this issue, the American Psychiatric Association is continuing their evaluation of the diagnostic criteria for the Internet Gaming Disorder and currently classifies it in Section III in “Conditions for Further Study” (p. 783). APA suggests that Internet Gaming Disorder has significant public health importance, and additional research may eventually lead to evidence that Internet Gaming Disorder (also referred to as Internet use disorder, Internet addiction, or gaming addiction) has merit as an independent disorder (APA, 2013a, p. 796).

References

American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. American Psychiatric Association. (2013b). Internet gaming disorder. Retrieved from http://www.dsm5.org/Documents/Internet%20Gaming%20Disorder%20Fact%20 Sheet.pdf Attwood, T. (2006). The complete guide to Asperger’s syndrome. London, UK: Jessica Kingsley Publishers. Barnett, J., & Coulson, M. (2010). Virtually real: A psychological perspective on massively multiplayer online games. Review of General , 14(2), 167- 179. Bleckmann, P., Eckert, J., & Jukschat, N. (2012). Futile search for a better life? Two biographical case studies on women with depression and video game dependency. Advances in Dual Diagnosis, 5(3), 137-146. Charlton, J. P., & Danforth, I. D. W., 2007. Distinguishing addiction and high engagement in the context of playing. Computers in Human Behavior, 23(3), 1531–1548. Dyszelski, C. J. (2006). Encounters at the imaginal crossroads: An exploration of the experiences of women in role-playing games. Unpublished doctoral dissertation. Miami University, Oxford, Ohio. Griffiths, M. D. (2008). Diagnosis and management of video game addiction. New Directions in Addiction Treatment and Prevention, 12, 27– 41. Griffiths, M. D. (2010). The role of context in online gaming excess and addiction: Some case study evidence. International Journal of Mental Health and Addiction, 8, 119–125. Griffiths, M. D., Davies, M. N. O., & Chappell, D. (2004). Online computer gaming: A comparison of adolescent and adult gamers. Journal of Adolescence, 27, 87–96. Hughes, J. (1988). Therapy is fantasy: Roleplaying, healing and the construction of symbolic order. Paper presented in Anthropology IV Honors, Medical Anthropology Seminar, Australian National University. Retrieved from http://www.rpgstudies.net/hughes/therapy_is_fantasy.html

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Jaffe, J. H. (1990). Trivializing dependence. British Journal of Addiction, 85(11), 1425– 1427. Krotoski, A. (2004). Chicks and joysticks: An exploration of women and gaming [White paper]. Entertainment and Leisure Software Publishers Association. Laber, E. (2001, January 11). Men are from Quake, women are from Ultima. The New York Times. Retrieved from http://www.nytimes.com/2001/01/11/technology/men-are-from-quake-women- are-from-ultima.html Mackay, D. (2001). The fantasy role-playing game: A new performing art. Jefferson, NC: McFarland & Company. Mehrabian, A., & Wixen, W. J. (1986). Preferences for individual video games as a function of their emotional effects on players. Journal of Applied Social Psychology, 16, 3–15. Morahan-Martin, J., & Schumacher, P. (2000). Incidence and correlates of pathological Internet use among college students. Computers in Human Behavior, 16(1), 13– 29. Myers, D. (1990). A Q-study of game player aesthetics. Simulation & Gaming, 21, 375– 396. Sorensen, K. H., Faulkner, W., & Rommes, E. (2012). Technologies of inclusion: Gender in the information society. Gender and Inclusion Policies for the Information Society. Trondheim, Norway: Akademika Publishing. Taylor, T. L. (2003). Multiple Pleasures: women and online gaming. Convergence, 9(1), 21-46. Wang, J., & He, M. (2000). Investigation of personality and mental health status of electronic game addicted adolescents and youth. Chinese Mental Health Journal, 14(5), 316. Williams, D., Yee, N., & Caplan, S. E. (2008). Who plays, how much, and why? Debunking the stereotypical profile. Journal of Computer Mediated Communication, 13, 993–1018. Yee, N. (2006). The psychology of MMORPGs: Emotional investment, motivations, relationship formation, and problematic usage. In R. Schroeder & A. Axelsson (Eds.), Avatars at work and play: Collaboration and interaction in shared virtual environments (pp. 187-207). London: Springer-Verlag. Yee, N. (October 2002). Ariadne: Understanding MMORPG addiction. Retrieved from http://www.nickyee.com/hub/addiction/addiction.pdf

Note: This paper is part of the annual VISTAS project sponsored by the American Counseling Association. Find more information on the project at: http://counselingoutfitters.com/vistas/VISTAS_Home.htm

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